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    MOC: Doctors strike back

    Underlying much of the controversy surrounding MOC is the question of how much—or even whether—the process as currently structured actually improves physician performance and/or patient outcomes.

    On February 3, 2015, many physicians received a surprising email from Richard Baron, MD, MACP, president and chief executive officer of the American Board of Internal Medicine (ABIM). Referring to the board’s controversial maintenance of certification (MOC) program, Baron wrote, “ABIM clearly got it wrong. We launched programs that weren’t ready and we didn’t deliver a MOC program that physicians found meaningful…We got it wrong and sincerely apologize. We are sorry. ”

    Baron’s email— which went to the approximately 200,000 internists and practitioners of 20 sub-specialties who have obtained their board certifications from the ABIM—followed by a few weeks (and many believe was at least partially in response to) the announcement a new organization, the National Board of Physicians and Surgeons (NBPAS), with the announced goal of giving doctors “an alternative route for continued board certification.” It is led by Paul Teirstein, MD, chief of cardiology at the Scripps Clinic in La Jolla, California, and an outspoken MOC critic.

    While the controversy surrounding MOC remains far from settled, it seems clear that critics of the process and of ABIM have scored some significant gains, by forcing ABIM to review or scrap some elements of MOC, and by possibly opening new paths to maintaining certification.

    Evolution of MOC requirements

    The creation of NBPAS and the ABIM’s apology are but the latest developments in a long-simmering dispute over how doctors should best keep their skills and knowledge up-to-date—and prove that they are doing so. The controversy dates to the 1990s, when the ABIM instituted a policy whereby, beginning in 2000, physicians who certified after 1990 would have to recertify every 10 years. (Until then certification had been life-long.) The change was subsequently adopted by the other 24 boards comprising the American Board of Medical Specialties (ABMS).

    The 10-year maintenance requirement produced some grumbling among doctors, but no organized resistance. That changed at the start of 2014 when ABIM announced that doctors would need to earn accreditation points on a continual basis over the 10 years between taking the recertifying examination. Moreover, doctors who had board certified before 1990 would be listed as “certified, not meeting MOC requirements” on the ABIM’s web site.

    Related: ABIM does about-face on changes to MOC program

    For Teirstein and many of the physicians boarded by the ABIM, these latest changes were the final straw. They were further incensed by what they regarded as the excessive growth of the nonprofit ABIM—whose budget exceeded $59 million—and the nearly $29 million spent on salaries, benefits and “other expenses” during the ABIM’s 2014 fiscal year. A few months later Teirstein launched an online petition opposing the MOC requirements that to-date has garnered more than 23,000 signatures, he says.

    In addition, he says, “I began getting comments like, ‘it’s great we have all these signatures, but what do we have to show for it? Have they [the ABIM] actually changed anything?’ And they had not.”


    NEXT: The NBPAS alternative


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      Surgeons aren't revolting against the MOC. why is that the cognitive doctors are so adverse to demonstrating their fund of knowledge? I have re-certified in general surgery and vascular surgery twice each, found the process to be a worthwhile and beneficial review. By devaluing your boards you negatively impact the credibility of your specialty. The specialty boards aren't flawless, but at least they are run by physicians in your specialty. Your guys are physicians, BOARD CERTIFIED in INTERNAL MEDICINE, NOT HEALTH CARE PROVIDERS. The last thing that medicine needs is fragmentation of the American Board of Medical Specialties. God only knows what it would be replaced with, but I can't imagine it would be more relevant or physician friendly. Did anyone tell you before you went to medical school that being a doctor was going to be easy? To paraphrase Kennedy, you chose to do it because it is hard. Yes it's hard, no it's not fair, but that's life and more specifically it's the life we chose. Pay your dues, take your test, and smoke a cigar with a glass of scotch when you pass, because for all the the garbage that we have been subjected to in recent years, such as "meaningless use," passing your exam, and maintaining your board certification will be something you can still feel proud about, and let's maintain some badly needed solidarity.
    • Anonymous
      "Surgeons aren't revolting against the MOC." Not true. Google "Stephen G. Weiss II, MD, FACS" and you'll find several pages where "Urologist Stephen G. Weiss II, MD, FACS, explains why he is voluntarily relinquishing his American Board of Urology certificate." Read his open letter to the ABU where he begins "As a board-certified urologist for almost fifteen years, I have jumped through every hoop the ABU has placed before me and have remained in good standing; however, I will no longer participate in the meaningless charade known as Maintenance of Certification (MOC). I successfully completed the original certification process and the subsequent recertification process, but enough is enough. The ABU has strayed far beyond its original mandate to ensure excellence in urologic training and has added yet another onerous burden onto the backs of practicing urologists." So sorry-- it's not just "cognitive doctors". But perhaps your surgical board is doing some good. Perhaps it hasn't spent its certification fees on a $2.3M condo in Philadelphia (Google "ABIM condo" or "ABIM MOC debate Charles Cutler"), or legal fees to sue and sanction diplomates for copyright infringement (try "ABIM Sarah Von Muller" and "ABIM frontrunners lawsuit"-- people who were preparing for an exam and got professionally dragged through the mud because the ABIM didn't like the test prep companies they signed up with). The problem is that the ABIM has done all of those things and worse. If you think that your professional abilities have less to do with your experience and training and more to do with your surgical board's recertification programs, I assure you that you're in the minority. But have at it. Keep throwing money at them and enjoy. You aren't dealing with the ABIM, their poor stewardship, greed, and bullying tactics. You have no idea what we've been dealing with and in that I envy you. But don't tell me to "Pay your dues, take your test, and smoke a cigar with a glass of scotch when you pass, because ... passing your exam, and maintaining your board certification will be something you can still feel proud about". That's a load of excrement. While I would like to take a hit of that 'cigar' you're smoking, I'll pass on your "glass of scotch" as I suspect someone has replaced it with Kool-Aid.
    • Mr. MWestfall
      Extremely well said
    • Anonymous
      To begin with, if the ABIM feels staying up to date is of paramount importance, then why did they grandfather all physicians who certified in 1990 or earlier? CME as required by the state board and maintaining a current medical license should be enough to maintain your board certification after passing the initial board exam. Taking a secured internal medicine exam over 11 specialities every 10 years achieves nothing more than demonstrating the ability to place a great deal of information in short term memory then regurgitate it for the exam. This serves no purpose and takes valuable time away from patient care. In the real world, decisions are not made in 2 minutes or less. Researching any topic in medicine can be done in minutes or we refer to our sub-speciality colleagues. The current ABIM MOC is a sham and should be abolished. All internists should switch to the NBPAS for maintaining their board certifications. They understand the true needs of physicians. The ABIM is nothing more than a harassing agency to the nations physicians.
    • Dr. Mohr
      I was proud to board certify in 1982. It was a distinction, a feather in my cap. I have recertified continuously since, but I will never again recertify with ABFP. The process amounts to annual recertification. It is expensive, time consuming and has been shown to have no clinical value. Why shouldn't this process be evidence based? If there is no evidence to support it, why do we do it? NBPAS, here I come!
      I agree. When one retires ABFP sends you a bill for ~one-half the annual dues to be a life-long member(no CME) and you don't practice! What BULL-S***/MOC is really for those who don't care to do learning on their own.
    • Dr. David W. Allison
      Attention ABIM, if I were you, I'd update my resume. Physicians are onto your corruption and we are going to run you scoundrels out of town on a rail!
    • Dr. Lance
      The American Board of Family Practice was the first certifying Board in the 70s to require re-exams and issue limited time certificates. Other boards followed gradually. Continuous professional development is essential. How it is done should be practice specific, low cost and respective of time spent. Hopefully Boards are getting that message and developing programs accordingly. The British experience and numerous studies being done will hopefully guide us to reach a professional and workable solution.
    • Anonymous
      It is a testament to the ABIM's lack of due diligence and nonexistent attention to detail for Baron to cite Dr. Larry Bush's early identification of anthrax and subsequent NEJM paper as arguments for the value of MOC. Searching for "Larry Bush" in the "Verify a physician's ABIM Certification"the ABIM.org site returns only one result-- Larry M. Bush (the NEJM article lists Dr. Bush's middle initial as "M"). He indeed is board certified: 1985 in Internal Medicine. And 1989 in INFECTIOUS DISEASE. So sorry Dr. Baron-- it wasn't a MOC-participating general internist who identified one of the early anthrax cases in 2001, but a grandfathered Infectious Disease specialist who likely never took a recertifying exam. Obviously if there were ANYONE I would expect to be able to identify the needle of a case of anthrax among the bales of hay, it would be an ID specialist. I'm not saying it'd be easy even for ID's, but I don't see how MOC factors in here. Especially since Dr. Bush doesn't participate in MOC. I'm serious-- that's what his record on ABIM.org shows. Check your own website. If there's some logic that Dr. Bush's work is a testament to MOC I'm not seeing it. Please explain. I have no doubts that Dr. Bush is a physician of the highest calibre. It is, however, clearly NOT because of anything done by the ABIM beyond 1989. I suppose ABIM will next take credit for bringing down the Berlin Wall and taking out Bin Laden.
    • Anonymous
      Excellent points! In addition, taking a test with a question on it doesn't drive learning. Is there feedback on what questions one gets wrong? No, because then they would be giving away the questions! So, having a question on the board exam on something has nothing to do with whether people learn it or not. This is clearly another desperate attempt to salvage their reputation and justify their excessive intrusion into our lives. I gave up on MOC a few years ago as it was irrelevant to my regular practice and too cumbersome. I'm already filling up my days fixing patients and staying on top of what will help them. The board wants me to take time away from figuring out what can help my patients and instead perform a little dance for them? Forget it!
    • Anonymous
      MOC has nothing to do with physician competency It is just a money grab by Baron to save the ABIM from bankruptcy. Nothing else, look at the books and where the money goes

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